序贯性机械通气治疗COPD并呼吸衰竭切换时点的随机对照研究

The Switching Point of Sequential Invasive to Noninvasive Ventilation in Treatment of Respiratory Failure with Chronic Obstructive Pulmonary Disease(COPD): A Randomized Controlled Trail

目的:通过随机对照研究对序贯性机械通气三种切换时点进行比较,以探索序贯通气治疗COPD并呼吸衰竭的最优切换点。方法:选择本院ICU住院的COPD合并Ⅱ型呼吸衰竭的患者90例,治疗采用有创-无创序贯机械通气策略,按随机数字表法分为三组,改良GCS评分组以改良GCS评分达到15分并稳定2 h以上为切换点、感染控制窗组以达到肺部感染控制窗为切换点、自主呼吸试验组以自主呼吸试验成功为切换点。观察并记录三组有创通气时间、总机械通气时间、入住ICU时间、呼吸机相关性肺炎(VAP)发生率、再插管率及死亡率等指标。结果:(1)改良GCS评分组及感染控制窗组有创机械通气时间、总机械通气时间、ICU住院时间、VAP发生率均低于自主呼吸试验组(P<0.05);(2)改良GCS评分组有创机械通气时间低于感染控制窗组(P<0.05),但两组总机械通气时间、ICU住院时间、VAP发生率等指标比较差异无统计学意义(P>0.05);(3)三组间再插管率、院内死亡率比较差异无统计学意义(P>0.05)。结论:虽然尚无证据证明三种不同的切换时机可降低死亡率,但改良GCS评分可全面反映患者的整体病情变化和机体状态,可最大限度地降低有创通气时间,降低VAP发生率及ICU住院时间,且应用简便、安全,是值得在临床推广的序贯机械通气策略。

Objective：To compare the three kinds of switching points of sequential mechanical ventilation（MV） with RCT,to evaluate which switching point is best for the treatment of sequential invasive to noninvasive ventilation in respiratory failure with chronic obstructive pulmonary disease（COPD）. Method：90 COPD patients with hypercapnic respiratory failure of ICU in our hospital were included in the study,which were divided into three groups according to random number table method：the Modified Glasgow Coma Scale（GCS）group was switched by the 15 points of Modified GCS scores and stable for 2 hours;the pulmonary infection control window（PIC window）group was switched by the achievement of pulmonary infection control window;the spontaneous breathing trial（SBT）group was switched by the success of spontaneous breathing trial. The invasive MV duration,total-MV duration,ventilator-associated pneumonia（VAP）,days in ICU, reintubation rate and mortality rate in three groups were measured. Result：（1）The Modified GCS group and the PIC window group were superior than the SBT group in the aspects of reducing the invasive MV duration,total-MV duration,VAP,days in ICU（P〈0.05）.（2）The Modified GCS group invasive mechanical ventilation time was lower than the the PIC window group （P〈0.05）,but total time of mechanical ventilation,ICU length of hospital stay,the incidence of VAP and other indicators of the two groups were compared,the differences had no statistical significance（P〉0.05）;（3）No difference were available among three groups in the aspects of reintubation rate and mortality rate（P〉0.05）. Conclusion：Though there is still no evidence to prove the three different switching points could reduce the mortality rate,switched by the Modified GCS score could reduced the invasive MV duration at the most and VAP,days in ICU,which could reflect the variation and the status of patient comprehensively ,easily and safely. Therefore,it is an efficient strategy to be recommended in the clinic application.